NCLEX Question Trainer Explanations
Test 7
1
,NCLEX Question Trainer Explanations
Test 7
1. The father of a one-day-old son works the evening shift (3 PM to 11 PM) at another
hospital. Which of the following plans would be a priority to meet the needs of this
father?
1. Encourage the father to call his wife after work.
2. Instruct the father about visiting policy and suggest AM visitation.
3. Adjust visiting hours to meet the new parents’ needs.
4. Present a change of visiting hours to the appropriate hospital committee.
Strategy: Answers are implementation. Determine the outcome of each answer. Is it
desired?
(1) inflexible
(2) inflexible
(3) correct–role of nurse is to be a family and client advocate; this provides
individualized care not a priority, although it may be an appropriate long-range
goal
(4) not a priority, although it may be an appropriate long-range goal
2. The nurse believes a coworker is diverting narcotics. The nurse approaches the nurse
manager to report the suspicions. Which of the following statements by the nurse is
BEST?
1. “After my coworker has been on duty, the patients often need repeated
doses of pain medication. I have seen her/him sleeping on duty three
times.”
2. “I saw my coworker downtown after work. S/he was acting really strange, like s/he
didn’t even recognize me.”
3. “I think my coworker is stealing narcotics because s/he is always acting euphoric
and seems high.”
4. “My coworker is hanging around with drug dealers, and I think I saw tracks on her/his
arms.”
Strategy: All answers are assessment. Determine how each relates to the situation.
(1) correct—report objective information that can be verified; clues to possible
substance abuse by staff include memory lapses, frequent absences from the
floor, increased number of clients reporting unrelieved pain or insomnia
(2) subjective observation
(3) subjective observation
(4) “hanging around with drug dealers” is subjective
2
, NCLEX Question
Trainer
3. A woman with chronic obstructive pulmonary disease (COPD) is admitted with
an acute exacerbation. Her vital signs are: BP 162/100, pulse 78, respirations
30 and labored with wheezing. The nurse should question which of the
following orders?
1. Theophylline (Somophyllin) 0.7 mg/kg/hr IV.
2. Tetracycline hydrochloride (Sumycin) 250 mg IM qd.
3. Ipratropium bromide (Atrovent) inhaler 2 inhalations qid.
4. Propranolol hydrochloride (Inderal) 40 mg PO bid.
Strategy: You are looking for an incorrect medication. Think about the action of each drug.
(1) drug of choice for acute asthma
(2) broad spectrum antibiotic, not contraindicated
(3) blocks parasympathetic stimulation and decreases mucus; used with asthma
(4) correct—beta-blocker that blocks beta adrenergic impulses to the bronchial
tree that cause bronchodilation resulting in increased bronchoconstriction
4. A husband and wife meet at the mental health clinic to make an appointment for
family therapy. Suddenly, the wife begins to sob loudly. As the nurse approaches, the
husband says, “I guess we just don’t get along.” Which of the following responses by
the nurse is MOST appropriate?
1. “Your wife seems to be upset by the situation.”
2. “Perhaps you should both go home now.”
3. “Try to think about what precipitated her crying.”
4. “The situation is difficult for both of you.”
Strategy: Remember therapeutic communication.
(1) nontherapeutic; emphasis is placed on wife, not the situation
(2) nontherapeutic; closes off communication
(3) nontherapeutic; appears to blame the husband for precipitating the wife’s
behavior, would cause him to react defensively
(4) correct—therapeutic; avoids blaming, focuses on feelings of both husband and wife
5. A client on chemotherapy has a WBC count of 1,200/mm3. Which of the following
nursing actions should the nurse take FIRST?
1. Check temperature q4h.
2. Monitor urine output.
3. Assess for bleeding gums.
4. Obtain an order for blood cultures.
Strategy: Determine how each assessment relates to a low white count.
(1) correct—important to monitor for infection which would be evidenced by
an elevated temperature in a client with a low WBC
(2) important because of problems of increased uric acid excretion from
chemotherapeutic drugs but should not be done first
(3) would be associated with a low platelet count
(4) would be done if the temperature were elevated to determine the type of organism
involved
3
, Preparation for the Nursing Licensure
Examination
6. A woman is in active labor with her first child when her membranes rupture. She
voices a concern to the nurse that she is afraid of having a “dry labor.” Which of the
following responses by the nurse would be MOST appropriate?
1. “The amniotic fluid provides only minimal lubrication for the labor process.”
2. “The amniotic sac may impede the progress of labor and is often ruptured
artificially.”
3. “Labor is only slightly more difficult with early rupture of the amniotic sac.”
4. “Because there is limited amniotic fluid, additional fluids will be supplied.”
Strategy: “MOST” indicates there may be more than one answer that you like.
(1) amniotic fluid cushions fetus, allows freedom of movement for musculoskeletal
development, facilitates symmetrical growth, maintains constant body
temperature, is a source of oral fluids, and collects wastes
(2) correct—sometimes done to assist or induce labor
(3) does not make labor more difficult
(4) no additional fluids will be supplied
7. The nurse is performing an ice massage for a client in chronic pain. The nurse is MOST
concerned if which of the following is observed?
1. Redness or inflammation of the tissue.
2. Mottling or graying of the tissue.
3. The client states that she feels a burning and tingling sensation in the area.
4. The client state that she feels a numbness and a cold sensation in the area.
Strategy: “MOST concerned” indicates a complication.
(1) indicates inflammation
(2) correct—site should be observed every five minutes for signs of tissue
intolerance, including blanching, mottling, or graying
(3) usually indicates ischemia or sensorineural impairment
(4) expected outcome of numbness, which would lead to decreased pain perception
8. The nurse is caring for a client with a complete heart block. The nurse should
question which of the following orders?
1. Administer lidocaine (Xylocaine) 50 mg IV push for PVCs in excess of six per minute.
2. Administer atropine sulfate (Atropine) 0.05 mg IV for symptomatic bradycardia.
3. Anticipate scheduling the client for a temporary pacemaker if the pulse continues to
decrease.
4. Mix 10 cc of 1:5,000 solution of isoproterenol (Isuprel) in 500 cc D5W for
sustained bradycardia below 30.
Strategy: All answers are implementation. Determine the outcome of each answer. Is it
desired?
(1) correct—in complete heart block, the AV node blocks all impulses from the SA
node so the atria and ventricles beat independently; because lidocaine suppresses
ventricular irritability, it may diminish the existing ventricular response; cardiac
depressants are contraindicated in the presence of complete heart block
(2) appropriate treatment
(3) appropriate treatment
52
Test 7
1
,NCLEX Question Trainer Explanations
Test 7
1. The father of a one-day-old son works the evening shift (3 PM to 11 PM) at another
hospital. Which of the following plans would be a priority to meet the needs of this
father?
1. Encourage the father to call his wife after work.
2. Instruct the father about visiting policy and suggest AM visitation.
3. Adjust visiting hours to meet the new parents’ needs.
4. Present a change of visiting hours to the appropriate hospital committee.
Strategy: Answers are implementation. Determine the outcome of each answer. Is it
desired?
(1) inflexible
(2) inflexible
(3) correct–role of nurse is to be a family and client advocate; this provides
individualized care not a priority, although it may be an appropriate long-range
goal
(4) not a priority, although it may be an appropriate long-range goal
2. The nurse believes a coworker is diverting narcotics. The nurse approaches the nurse
manager to report the suspicions. Which of the following statements by the nurse is
BEST?
1. “After my coworker has been on duty, the patients often need repeated
doses of pain medication. I have seen her/him sleeping on duty three
times.”
2. “I saw my coworker downtown after work. S/he was acting really strange, like s/he
didn’t even recognize me.”
3. “I think my coworker is stealing narcotics because s/he is always acting euphoric
and seems high.”
4. “My coworker is hanging around with drug dealers, and I think I saw tracks on her/his
arms.”
Strategy: All answers are assessment. Determine how each relates to the situation.
(1) correct—report objective information that can be verified; clues to possible
substance abuse by staff include memory lapses, frequent absences from the
floor, increased number of clients reporting unrelieved pain or insomnia
(2) subjective observation
(3) subjective observation
(4) “hanging around with drug dealers” is subjective
2
, NCLEX Question
Trainer
3. A woman with chronic obstructive pulmonary disease (COPD) is admitted with
an acute exacerbation. Her vital signs are: BP 162/100, pulse 78, respirations
30 and labored with wheezing. The nurse should question which of the
following orders?
1. Theophylline (Somophyllin) 0.7 mg/kg/hr IV.
2. Tetracycline hydrochloride (Sumycin) 250 mg IM qd.
3. Ipratropium bromide (Atrovent) inhaler 2 inhalations qid.
4. Propranolol hydrochloride (Inderal) 40 mg PO bid.
Strategy: You are looking for an incorrect medication. Think about the action of each drug.
(1) drug of choice for acute asthma
(2) broad spectrum antibiotic, not contraindicated
(3) blocks parasympathetic stimulation and decreases mucus; used with asthma
(4) correct—beta-blocker that blocks beta adrenergic impulses to the bronchial
tree that cause bronchodilation resulting in increased bronchoconstriction
4. A husband and wife meet at the mental health clinic to make an appointment for
family therapy. Suddenly, the wife begins to sob loudly. As the nurse approaches, the
husband says, “I guess we just don’t get along.” Which of the following responses by
the nurse is MOST appropriate?
1. “Your wife seems to be upset by the situation.”
2. “Perhaps you should both go home now.”
3. “Try to think about what precipitated her crying.”
4. “The situation is difficult for both of you.”
Strategy: Remember therapeutic communication.
(1) nontherapeutic; emphasis is placed on wife, not the situation
(2) nontherapeutic; closes off communication
(3) nontherapeutic; appears to blame the husband for precipitating the wife’s
behavior, would cause him to react defensively
(4) correct—therapeutic; avoids blaming, focuses on feelings of both husband and wife
5. A client on chemotherapy has a WBC count of 1,200/mm3. Which of the following
nursing actions should the nurse take FIRST?
1. Check temperature q4h.
2. Monitor urine output.
3. Assess for bleeding gums.
4. Obtain an order for blood cultures.
Strategy: Determine how each assessment relates to a low white count.
(1) correct—important to monitor for infection which would be evidenced by
an elevated temperature in a client with a low WBC
(2) important because of problems of increased uric acid excretion from
chemotherapeutic drugs but should not be done first
(3) would be associated with a low platelet count
(4) would be done if the temperature were elevated to determine the type of organism
involved
3
, Preparation for the Nursing Licensure
Examination
6. A woman is in active labor with her first child when her membranes rupture. She
voices a concern to the nurse that she is afraid of having a “dry labor.” Which of the
following responses by the nurse would be MOST appropriate?
1. “The amniotic fluid provides only minimal lubrication for the labor process.”
2. “The amniotic sac may impede the progress of labor and is often ruptured
artificially.”
3. “Labor is only slightly more difficult with early rupture of the amniotic sac.”
4. “Because there is limited amniotic fluid, additional fluids will be supplied.”
Strategy: “MOST” indicates there may be more than one answer that you like.
(1) amniotic fluid cushions fetus, allows freedom of movement for musculoskeletal
development, facilitates symmetrical growth, maintains constant body
temperature, is a source of oral fluids, and collects wastes
(2) correct—sometimes done to assist or induce labor
(3) does not make labor more difficult
(4) no additional fluids will be supplied
7. The nurse is performing an ice massage for a client in chronic pain. The nurse is MOST
concerned if which of the following is observed?
1. Redness or inflammation of the tissue.
2. Mottling or graying of the tissue.
3. The client states that she feels a burning and tingling sensation in the area.
4. The client state that she feels a numbness and a cold sensation in the area.
Strategy: “MOST concerned” indicates a complication.
(1) indicates inflammation
(2) correct—site should be observed every five minutes for signs of tissue
intolerance, including blanching, mottling, or graying
(3) usually indicates ischemia or sensorineural impairment
(4) expected outcome of numbness, which would lead to decreased pain perception
8. The nurse is caring for a client with a complete heart block. The nurse should
question which of the following orders?
1. Administer lidocaine (Xylocaine) 50 mg IV push for PVCs in excess of six per minute.
2. Administer atropine sulfate (Atropine) 0.05 mg IV for symptomatic bradycardia.
3. Anticipate scheduling the client for a temporary pacemaker if the pulse continues to
decrease.
4. Mix 10 cc of 1:5,000 solution of isoproterenol (Isuprel) in 500 cc D5W for
sustained bradycardia below 30.
Strategy: All answers are implementation. Determine the outcome of each answer. Is it
desired?
(1) correct—in complete heart block, the AV node blocks all impulses from the SA
node so the atria and ventricles beat independently; because lidocaine suppresses
ventricular irritability, it may diminish the existing ventricular response; cardiac
depressants are contraindicated in the presence of complete heart block
(2) appropriate treatment
(3) appropriate treatment
52
